the nurse is assisting with the admission of a young adult female korean exchange student with acute abdominal pain although the client has been able
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Nursing Elites

HESI LPN

HESI PN Exit Exam 2024

1. The nurse is assisting with the admission of a young adult female Korean exchange student with acute abdominal pain. Although the client has been able to easily answer questions, when asked about sexual activity, she looks away. What action should the nurse take?

Correct answer: D

Rationale: Observing the client's response to another question is the most appropriate action in this scenario. By doing so, the nurse can assess whether the client's discomfort is due to cultural sensitivity or a misunderstanding. This approach allows the nurse to proceed with sensitivity and respect, ensuring effective communication. Option A is incorrect because omitting the section of the assessment form may result in missing crucial information relevant to the client's condition. Option B jumps to assumptions about a language barrier without confirming it first. Option C focuses on rewording the question without addressing the underlying issue causing the client's discomfort, which may not necessarily be due to a lack of understanding.

2. After admission, which observation is most important for the nurse to report immediately for an adult client who weighs 150 pounds and has partial-thickness and full-thickness burns over 40% of the body from a house fire?

Correct answer: D

Rationale: A urinary output of 20 ml/hr is a sign of inadequate kidney perfusion and could indicate hypovolemic shock, which requires immediate intervention. In this situation, with severe burns over a large portion of the body, monitoring urinary output is crucial to assess kidney function and fluid status. Poor appetite, systolic blood pressure at 102, and painful moaning and crying are important but do not indicate the immediate need for intervention like inadequate urinary output does.

3. A client who had an abdominal hysterectomy is experiencing minimal urine output despite adequate fluid intake. What should the nurse assess first?

Correct answer: C

Rationale: Assessing the patency of the urinary catheter is crucial in this situation. A blocked catheter could be a common cause of decreased urine output following surgery. While checking the IV catheter insertion site (Choice B) is important, it is not the priority in this case. Examining the client's bladder for distension (Choice A) is relevant, but assessing the patency of the catheter takes precedence in resolving the issue of decreased urine output. Monitoring vital signs (Choice D) is a routine nursing task but not the priority when dealing with decreased urine output post-surgery.

4. An older male client with Alzheimer's disease is admitted to an extended care facility. Which intervention should the PN include in the client's nursing care plan?

Correct answer: A

Rationale: The correct intervention for a client with Alzheimer's disease in an extended care facility is to plan to have the same nursing staff provide care whenever possible. Consistency in caregivers helps reduce confusion and anxiety in clients with Alzheimer’s disease, promoting a stable and supportive environment for the client. Choice B is incorrect as it focuses on activities rather than the consistency of caregivers. Choice C is incorrect as it suggests isolating the client, which can lead to increased confusion and distress. Choice D is incorrect as introducing the client to new people immediately can be overwhelming and may exacerbate their symptoms.

5. The nurse is providing care for a client with type 1 diabetes mellitus who is receiving NPH insulin. The nurse notices that the client's evening glucose levels are consistently above 260 mg/dl. What does this indicate?

Correct answer: C

Rationale: High evening glucose levels suggest that the current insulin dosage may be inadequate to control the client's blood sugar levels effectively. This indicates poor glycemic control and the need for a possible adjustment in the insulin regimen. Option A describes symptoms of peripheral neuropathy, which are not directly related to the elevated glucose levels but may be a long-term complication of diabetes. Option B describes a wound infection, which is not directly related to the client's high glucose levels. Option D mentions morning nausea, which could be due to various causes and is not directly related to the high evening glucose levels.

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